In India today, two deaths occur
every three minutes from tuberculosis (TB). But these deaths can be
prevented. With proper care and treatment, TB patients can be
cured and the battle against TB can be
won

Tuberculosis (TB) is an infectious disease caused by a Bacterium,
Mycobacterium tuberculosis. It is spread through the air by a person suffering
from TB. A single patient can infect 10 or more people in a year.

India has a long and distinguished
tradition of research in TB. Studies from the Tuberculosis Research Centre in
Chennai and the National Tuberculosis Institute in Bangalore provided key
knowledge to improve treatment of TB patients all around the world.

Modern anti-TB treatment can cure
virtually all patients. It is, however, very important that treatment be taken
for the prescribed duration, which in every case is a minimum of 6 months.
Because treatment is of such a long duration and patients feel better after
just 1-2 months, and because many TB patients face other problems such as
poverty and unemployment, treatment is often interrupted.

Therefore, just providing anti-TB
medication is not sufficient to ensure that patients are cured. The DOTS
strategy ensures that infectious TB patients are diagnosed and treated
effectively till cure, by ensuring availability of the full course of drugs and
a system for monitoring patient compliance to the treatment.

The DOTS strategy along with the other components of the Stop TB
strategy, implemented under the Revised National Tuberculosis Control Programme
(RNTCP) in India, is a comprehensive package for TB control.

The DOTS strategy is cost-effective
and is today the international standard for TB control programmes. To date,
more than 180 countries are implementing the DOTS strategy. India has adapted
and tested the DOTS strategy in various parts of the country since 1993, with
excellent results, and by March 2006 nationwide DOTS coverage has been
achieved.

Political and administrative commitment. TB is the leading infectious cause of
death among adults.
TB
kills more men than women, yet more women die of TB than all
causes associated with childbirth combined. Since TB can be
cured and the epidemic reversed, it warrants
the topmost priority, which it has been accorded
by the Government of India. This
priority must be continued and expanded at
the state, district and local levels.

Good
quality diagnosis. Good quality microscopy allows
health workers to see the tubercle bacilli and is essential
to identify the infectious patients who need treatment the
most.

Good
quality drugs. An uninterrupted supply of good quality anti-TB drugs must be available. In the RNTCP, a
box of medications for the entire treatment is earmarked for
every patient registered, ensuring the availability of the
full course of treatment the moment the patient is initiated
on treatment. Hence in DOTS, the treatment can never
interrupt for lack of medicine.

Supervised
treatment to ensure the right treatment, given in
the right way. The RNTCP uses the best anti-TB medications
available. But unless treatment is made convenient for
patients, it will fail. This is why the heart of the DOTS
programme is "directly observed treatment" in which a health
worker, or another trained person who is not a family
member, watches as the patient swallows the anti-TB
medicines in their presence.

Systematic
monitoring and accountability. The programme is
accountable for the outcome of every patient treated. This
is done using standard recording and reporting system, and
the technique of ‘cohort analysis’. The cure rate and other
key indicators are monitored at every level of the health
system, and if any area is not meeting expectations,
supervision is intensified. The RNTCP shifts the
responsibility for cure from the patient to the health
system.

The
new Stop TB Strategy published by WHO in 2006 has DOTS in the
core with additional components to address TB/HIV and MDR-TB,
health system strengthening, involvement of all care
providers, engaging people with TB and affected communities,
and enabling/promoting research. RNTCP is already
implementing/ plans to implement the activities recommended
under the new Stop TB Strategy.

Controlling TB in
India is a tremendous challenge. The TB burden in India is still staggering.
Every year, 1.8 million persons develop the disease, of which about 800,000 are
infectious; and, until recently, 370,000 died of it annually —1,000 every day.
The disease is a major barrier to social and economic development. An estimated
100 million workdays are lost due to illness. Society and the country also
incur a huge cost due to TB—nearly US$ 3 billion in indirect costs and US$ 300
million in direct costs.

The Revised National Tuberculosis
Control Programme (RNTCP), based on the DOTS strategy, began as a pilot in 1993
and was launched as a national programme in 1997. Rapid RNTCP expansion began
in late 1998. By the end of 2000, 30%of the country’s population was covered,
and by the end of 2002, 50%of the country’s population was covered under the
RNTCP. By the end of 2003, 778 million population was covered, and at the end
of year 2004 the coverage reached to 997 million. By December 2005, around 97%
(about 1080 million) of the population had been covered, and the entire country
was covered under DOTS by 24th March 2006.

Every day in India, under the RNTCP,
more than 15,000 suspects are being examined for TB, free of charge. The
diagnosis of these patients and the follow-up of patients on treatment is
achieved through the examination of more than 50,000 laboratory specimens. As a
result of these examinations, each day, about 3,500 patients are started on
treatment, stopping the spread of TB in the community. In order to achieve
this, more than 600,000 health care workers have been trained and more than
11,500 designated laboratory Microscopy Centres have been upgraded and supplied
with binocular microscopes since the inception of the RNTCP.

As a result of rapid expansion in
diagnostic facilities, the proportion of sputum- positive cases confirmed in
the laboratory are double that of the previous programme and is on par with
international standards. Despite the rapid expansion, overall performance
remains good and in many areas is excellent. Treatment success rates have
tripled from 25%in the earlier programme to 86%in RNTCP.

In 1992, the
Government of India, together with the World Health Organization (WHO) and
Swedish International Development Agency (SIDA), reviewed the National TB
Programme and concluded that it suffered from managerial weakness, inadequate
funding, over-reliance on x-ray, non-standard treatment regimens, low rates of
treatment completion, and lack of systematic information on treatment outcomes.
Programme review showed that only 30% of patients were diagnosed and only 30%
of those treated successfully. Based on the findings and recommendations of the
review in 1992, the GOI evolved a revised strategy and launched the Revised
National TB Control Programme (RNTCP) in the country. Starting as
pilots in October 1993, the RNTCP was implemented in a population of 2.35
million in 5 sites in different states (Delhi, Kerala, West Bengal,
Maharashtra, and Gujarat). The programme was expanded to a population of 13.85
million in 1995 and 16 million in 1996. Having proved both its technical and
operational feasibility, a soft loan of US $ 142 million was negotiated with
the World Bank in December 1996 and the credit agreement was signed with IDA in
May 1997. In 1997 RNTCP was launched as a national programme. It was envisaged
to implement RNTCP in 102 districts of the country covering a population of 271
million in a phased manner. Another 203 SCC districts with a population of 447
million were envisaged to be strengthened as a transitional step for
introduction of revised strategy at a later stage. Having started in 1997,
rapid scale-up began in late 1998, when another 100 million populations was
covered under RNTCP. Over the years RNTCP has expanded rapidly as shown below:

Year

1998

1999

2000

2001

2002

2003

2004

2005

March
2006

Population
Covered *

18

130

287

450

530

775

947

1080

1114

*
cumulative, in millions

Starting in 1997, the project was
implemented in a phased manner to ensure that quality of services is
maintained. By March 2006, entire country has been covered under the programme.

Revised National TB Control Programme
and its recent progress in DOTS expansion has been encouraging. As per Global
TB Report 2003, 2/3rd of the additional sputum positive cases reported under
DOTS in 2001, were found in India. In 2002, over 620,000 cases were placed on
treatment of which nearly 250,000 were new smear positive cases. In the year
2003, more than 900,000 cases were placed on treatment. In the year 2004 alone
more than 1100,000 cases were placed on treatment, and in the 2005, more than
1290,000 cases were placed on treatment - largest cohort of cases, more
than any other country in the world . By December 2009, more than 11 million patients have been initiated on treatment, saving more than 2 million additional lives. The success of DOTS in India has contributed
substantially to the success of TB control in the world.

RNTCP has consistently achieved treatment success rate of more than 85%, and case detection close to the global target. However, in 2007 RNTCP for the first time has achieved the global target of 70% case detection while maintaining the treatment success rate of more than 85%.

TB is the most common opportunistic infection in people living
with HIV virus. As the HIV breaks down the immune system, HIV- infected people
are at greatly increased risk of TB. Without HIV, the lifetime risk of
developing TB in TB-infected people is 10%, compared to at least 50% in HIV
co-infected. HIV is also the most powerful risk factor for progression from TB
infection to TB disease. TB in turn accelerates the progression of HIV to AIDS
and shortens the survival of patients with HIV infection. Thus, TB and HIV are
closely interlinked. In India there are an estimated over 5 million
HIV-infected persons.

With such large numbers of
HIV-positive individuals in India, it is likely that HIV may worsen the TB
epidemic in the absence of a robust TB control programme. However, even among
HIV-infected people, TB can be cured. Directly Observed Treatment, Short-course
(DOTS) is as effective among HIV- infected TB patients as among those who are
HIV negative.

MDRTB refers to strains of the bacterium which are proven in a
laboratory to be resistant to the two most active anti-TB drugs, isoniazid and
rifampicin. Treatment of MDRTB is extremely expensive, toxic, arduous, and
often unsuccessful.

DOTS has been proven to prevent the emergence of MDRTB, and also
to reverse the incidence of MDRTB where it has emerged. MDRTB is a tragedy for
individual patients and a symptom of poor TB management. The best way to
confront this challenge is to improve TB treatment and implement DOTS.

Beginning 1999, the Tuberculosis Research Centre, Chennai in collaboration with
the National Tuberculosis Institute, Bangalore, initiated drug resistance
surveys in different parts of the country using the WHO/IUATLD guidelines. The
table below provides information about primary isoniazid resistance and primary
multi-drug resistance based on analyses completed to date.

Table:
Primary drug resistance, India (1999-2002)

District (Zone)

Intake period

Number of patients

Primary isoniazid
resistance %

Primary multi-drug resistance %

North Arcot
(South)

1999

282

23.4

2.8

f

Raichur
(South)

1999-2000

278

18.7

2.5

Wardha
(West)

2000-2001

197

15

0.5

Jabalpur
(West)

2001-2002

273

17

1.0

Hoogly
(East)

2000-2001

350

10.3

3.0

Mayurbanj
(East)

2000-2002

343

2.5

0.7

Currently large scale representative drug
resistance surveys are on-going in 2 States and 3 (Andhra
Pradesh, Orissa, Uttar Pradesh) other States are likely to
conduct these
surveys.

RNTCP
is planning to introduce second line anti-TB treatment for
MDR-TB cases, starting in early 2007. For this purpose State
level Intermediate Reference Laboratories are being
established to provide quality assured culture and drug
susceptibility testing facilities. The guidelines for
management of MDR-TB under DOTS-Plus strategy have been
developed.

In the first phase of
RNTCP (1998-2005), the programme’s focus was on ensuring
expansion of quality DOTS services to the entire country.
There are many challenges remaining that are to be addressed
in order to achieve the TB-related targets set by the
Millennium Development Goals for 2015 and to achieve TB
control in the longer
term.

The RNTCP has
now entered its second phase in which the programme aims to
firstly consolidate the gains made to date, to widen services
both in terms of activities and access, and to sustain the
achievements for decades to come in order to achieve ultimate
objective of TB control in the country.

All components
of new Stop TB Strategy are incorporated in
the second phase of RNTCP. These are:

Pursue
quality DOTS expansion and enhancement, by
improving the case finding are cure through an effective
patient-centred approach to reach all patients, especially
the poor.

Address
TB-HIV, MDR-TB and other challenges, by scaling up
TB-HIV joint activities, DOTS Plus, and other relevant
approaches.

Contribute
to health system strengthening, by collaborating
with other health programmes and general
services

Involve
all health care providers, public, nongovernmental
and private, by scaling up approaches based on a
public-private mix (PPM), to ensure adherence to the
International Standards of TB care.

Engage
people with TB, and affected communities to demand,
and contribute to effective care. This will involve
scaling-up of community TB care; creating demand thorugh
context-specific advocacy, communication and social
mobilization.

Enable
and promote research for the development of new
drugs, diagnostic and vaccines. Operational Research will
also be needed to improve programme performance.

The Revised
National TB Control Programme now aims to widen the scope for
providing standardized, good quality treatment and diagnostic
services to all TB patients in a patient-friendly environment,
in which ever health care facility they seek treatment from.
Recognizing the need to reach to every TB patient in the
country, the programme has made special provisions to reach
marginalized sections of the society, including creating
demand for services through specific advocacy, communication
and social mobilization activities.

For more information contact the State TB Cell or
District TB
Centre
in your area